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Poor Maternity Care At Shrewsbury And Telford NHS Trust – The Final Ockenden Report

It is now 15 months since Donna Ockenden produced her preliminary findings of the review of maternity care provided at the Shrewsbury and Telford NHS Trust.

The final review is truly comprehensive, and has far reaching implications well beyond the Shrewsbury and Telford NHS Trust that was the subject of the review. Click here for the full report.

A summary of review findings taken from the final report shows:

The final number of families whose cases were reviewed was 1,486. The vast majority of these were between 2000 and 2019, with 170 cases pre-2000 and 15 post 2019. All the clinical incidents were reviewed by members of the review team, which comprised obstetricians, midwives, neonatologists and other specialists, where appropriate. The clinical care was graded using an established grading of care scoring system:

Grade Summary description of care Detailed description of care

of care
Detailed description of care
0AppropriateAppropriate care in line with best practice at the time
1Minor concernsCare could have been improved, but different management would have made no difference to the outcome
2Significant concernsSuboptimal care in which different management might have made a difference to the outcome
3Major concernsSuboptimal care in which different management would reasonably be expected to have made a difference to the outcome


There were 12 maternal deaths reviewed and, in 9 of the 12 cases (75%), the review team identified significant or major concerns in the care received.

498 cases of stillbirth were reviewed and graded. One in four cases (25%) were found to have significant or major concerns in care which, if managed appropriately, might or would have resulted in a different outcome.

Hypoxic ischaemic encephalopathy (‘HIE’) is a newborn brain injury caused by oxygen deprivation to the brain. There were significant and major concerns in the care provided to the mother in two-thirds (65.9%) of all cases. After the baby had been born, most of the neonatal care provided was considered appropriate or included minor concerns – however, these were unlikely to influence the outcome observed.

Most of the neonatal deaths occurred in the first 7 days of life. Nearly a third of all incidents reviewed (27.9%) were identified to have significant or major concerns in the maternity care that might or would have resulted in a different outcome.

Cerebral palsy or brain damage

All of the families in this group self-reported to the review. The diagnosis of cerebral palsy was often made some years following their maternity episode. After some re-categorisation into the HIE group, from the remaining cases of cerebral palsy more than 40% were identified to have significant or major concerns in maternity care which might have resulted in a different outcome. The grading of neonatal care in most of the cases was either appropriate or with only minor concerns.

Maternal morbidity

There were 614 women in this group, and they included women who:

  • experienced morbidity such as admission to intensive care
  • had had a caesarean hysterectomy
  • had severe sepsis or major haemorrhage, or reported having experienced rare adverse outcomes such as eclampsia, amniotic fluid embolus or a cardiac arrest.

Reviewers identified significant and major concerns in the care provided to 1 in 4 (25%) women in this group. The care provided to the baby was considered appropriate in more than 90% of records reviewed.

What is evident is that there were many reviews and investigations into performance at the Trust in the past, some of which had highlighted concerns, but overall the Trust was given a clean bill of health. These can be seen in the helpful timeline set out in the report summary. Click here to see summary off findings, conclusions and essential actions.

The report reveals a reluctance to have shortcomings revealed, noting in particular the critical Royal College of Obstetricians and Gynaecologists report of 2017, which was not well received by the Trust (who sought to delay presentation to the Trust board and underplay the findings/treat them as historic and resolved), missing an opportunity for honest reflection and improvement.

The review also found clear evidence of a lack of appropriate and comprehensive independent investigation and poor family involvement. Of real concern is the fact that the summary indicates that “In the final weeks leading up to publication of the report, a number of staff withdrew their co-operation from the report and therefore their content (or ‘voice’) was lost from the report. The main reason for withdrawing from the report as cited by staff was fear of being identified. This was despite our reassurance that staff would only ever be identified as ‘a staff member told the review team…’’.

The report prompted an Oral Statement to Parliament by the Secretary of State for Health and Social Care, Sajid Javid, in which he paid tribute to the families who were the powerful driving force behind the review and pledged his support to implement the recommendations, including the need to further expand the maternity workforce. The government have already committed to create a Special Health Authority to continue the Maternity Investigation Programme that is currently run by the Healthcare Safety Investigation Branch, and the SHA will start its work from April next year.

It remains to be seen whether words translate into actions and measurable improvements, but this surely has to be a step in the right direction.